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<title>HIPAA_Part_I_and_Part_II_invisible Page1</title>

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<div id="t1_1" class="text" style="word-spacing: 16px; font-size: 14px;">Southeast Quadrant MCCU </div>
<div id="t2_1" class="text" style="word-spacing: 13px; font-size: 11px;">Patie nt Nam e : _____________________________________________ Trans port D ate : _____________________________________ </div>
<div id="t3_1" class="text" style="word-spacing: 4px; font-size: 10px;">Privacy Practice s Acknowle dgm e nt:</div>
<div id="t4_1" class="text" style="word-spacing: 2px; font-size: 10px;">b y sig ning  b e low, the  sig ne r acknowle d g e s that </div>
<div id="t5_1" class="text" style="word-spacing: 2px; font-size: 10px;">Southe ast Quadrant M CCU (SEQ M CCU)</div>
<div id="t6_1" class="text" style="word-spacing: 2px; font-size: 10px;">p rovid e d  a </div>
<div id="t7_1" class="text" style="word-spacing: 3px; font-size: 10px;">cop y of its Notice  of Privacy Practice s to the  p atie nt or othe r party with instructions to provide  the  Notice  to the  p atie nt. </div>
<div id="t8_1" class="text" style="word-spacing: 4px; font-size: 10px;">*A copy of this form  is valid as an original*</div>
<div id="t9_1" class="text" style="word-spacing: 5px; font-size: 10px;">This is a sample only and does not constitute legal advice. </div>
<div id="t10_1" class="text" style="word-spacing: 7px; font-size: 10px;">User bears all responsibility for compliance with all applicable laws and regulations. </div>
<div id="t11_1" class="text" style="word-spacing: 3px; font-size: 10px;">This is a sample o </div>
<div id="t12_1" class="text" style="word-spacing: 3px; font-size: 10px;">On the  line  b e low, e xp lain the  circumstance s that make  it impractical for the  p atie nt to sig n: </div>
<div id="t13_1" class="text" style="word-spacing: 0px; font-size: 10px;">__________________________________________________________________________________________________________________________ </div>
<div id="t14_1" class="text" style="word-spacing: 2px; font-size: 10px;">I am signing  on b e half of the  p atie nt to authorize  the  sub mission of a claim for p ayme nt to Me d icare , Me d icaid , or any othe r p ayor for any se rvice s </div>
<div id="t15_1" class="text" style="word-spacing: 1px; font-size: 10px;">p rovid e d  to the  p atie nt b y </div>
<div id="t16_1" class="text" style="word-spacing: 0px; font-size: 10px;">SEQ M CCU</div>
<div id="t17_1" class="text" style="word-spacing: 2px; font-size: 10px;">now or in the  p ast, (or in the  future , whe re  p e rmitte d ). </div>
<div id="t18_1" class="text" style="word-spacing: 3px; font-size: 10px;">By sig ning  b e low, I acknowle dg e  that I am one  of the  </div>
<div id="t19_1" class="text" style="word-spacing: 3px; font-size: 10px;">authorize d  sig ne rs liste d  b e low. </div>
<div id="t20_1" class="text" style="word-spacing: 3px; font-size: 10px;">M y signature  is not an acceptance  of financial re sponsibility for the  se rvice s re nde red.</div>
<div id="t21_1" class="text" style="word-spacing: 3px; font-size: 10px;">Authorize d  re pre se ntative s includ e  </div>
<div id="t22_1" class="text" style="font-size: 10px;">only</div>
<div id="t23_1" class="text" style="word-spacing: 9px; font-size: 10px;">the  following  ind ividuals: </div>
<div id="t24_1" class="text" style="font-size: 10px;"></div>
<div id="t25_1" class="text">Patie nt’s le g al g uardian </div>
<div id="t26_1" class="text" style="font-size: 10px;"></div>
<div id="t27_1" class="text">Re lative  or othe r p e rson who re ce ive s social se curity or othe r g ove rnme ntal b e ne fits on b e half of the  p atie nt </div>
<div id="t28_1" class="text" style="font-size: 10px;"></div>
<div id="t29_1" class="text">Re lative  or othe r p e rson who arrang e s for the  p atie nt’s tre atme nt, or e xe rcise s othe r re sp onsib ility for the  p atie nt’s affairs </div>
<div id="t30_1" class="text" style="font-size: 10px;"></div>
<div id="t31_1" class="text">Re p re se ntative  of an ag e ncy or institution that d id  not furnish the  se rvice s for which p ayme nt is claime d  (i.e ., amb ulance  se rvice s) b ut furnishe d  </div>
<div id="t32_1" class="text" style="word-spacing: 3px; font-size: 10px;">othe r care , se rvice s, or assistance  to the  p atie nt </div>
<div id="t33_1" class="text" style="word-spacing: 0px; font-size: 10px;">X _________________________________ </div>
<div id="t34_1" class="text" style="word-spacing: 0px; font-size: 10px;">___________  __________________________________________________________________________ </div>
<div id="t35_1" class="text" style="word-spacing: 3px; font-size: 10px;">Re p re se nta tive  Sig nature  </div>
<div id="t36_1" class="text" style="word-spacing: 0px; font-size: 10px;">Date  </div>
<div id="t37_1" class="text" style="word-spacing: 2px; font-size: 10px;">Printe d  Na m e  a nd  Ad d re ss of Re p re se nta tive  </div>
<div id="t38_1" class="text" style="word-spacing: 1px; font-size: 7px;">I a u th o rize  th e  su b m issio n  o f a  cla im  fo r p a y m e n t to  Me d ica r e , Me d ica id , o r  a n y  o th e r p a y o r fo r a n y  se rvic e s p r o vid e d  to  m e  b y  </div>
<div id="t39_1" class="text" style="word-spacing: 1px; font-size: 7px;">SEQ  M C C U</div>
<div id="t40_1" class="text">n o w , in  th e  p a st, o r in  th e  fu tu re . I </div>
<div id="t41_1" class="text" style="word-spacing: 1px; font-size: 7px;">u n d e rsta n d  th a t I a m  fin a n c ia lly  re sp o n sib le  fo r th e  se r vic e s a n d  su p p lie s p ro vid e d  to  m e  b y  </div>
<div id="t42_1" class="text" style="word-spacing: 1px; font-size: 7px;">SEQ  M C C U</div>
<div id="t43_1" class="text">, r e g a r d le ss o f m y  in su ra n c e  c o ve ra g e , a n d  in  so m e  c a se s, m a y  b e  </div>
<div id="t44_1" class="text" style="word-spacing: 1px; font-size: 7px;">re sp o n sib le  fo r a n  a m o u n t in  a d d itio n  to  th a t w h ic h  w a s p a id  b y  m y  in su ra n c e . I a g re e  to  im m e d ia te ly  re m it to  </div>
<div id="t45_1" class="text" style="word-spacing: 1px; font-size: 7px;">SEQ  M C C U</div>
<div id="t46_1" class="text">a n y  p a y m e n ts th a t I re ce ive  d ire ctly  fro m  in su ra n c e  o r a n y  </div>
<div id="t47_1" class="text" style="word-spacing: 1px; font-size: 7px;">so u rc e  w h a tso e ve r fo r th e  se r vic e s p r o vid e d  to  m e  a n d  I a ssig n  a ll rig h ts to  su c h  p a y m e n ts to  </div>
<div id="t48_1" class="text" style="word-spacing: 1px; font-size: 7px;">SEQ  M C C U</div>
<div id="t49_1" class="text">. I a u th o rize  </div>
<div id="t50_1" class="text" style="word-spacing: 1px; font-size: 7px;">SEQ  M C C U</div>
<div id="t51_1" class="text">to  a p p e a l p a y m e n t d e n ia ls o r o th e r a d ve rse  </div>
<div id="t52_1" class="text" style="word-spacing: 1px; font-size: 7px;">d e cisio n s o n  m y  b e h a lf w ith o u t fu rth e r a u th o riza tio n . I a u th o rize  a n d  d ire ct a n y  h o ld e r o f m e d ica l in fo r m a tio n  o r o th e r r e le va nt d o cu m e n ta tio n  a b o u t m e  to  re le a s e  su ch  in fo r m a tio n  to  </div>
<div id="t53_1" class="text" style="word-spacing: 1px; font-size: 7px;">SEQ  M C C U</div>
<div id="t54_1" class="text">a n d  its b illin g  a g e n ts, th e  C e n te rs fo r Me d ic a re  a n d  Me d ic a id  Se rvic e s, a n d / o r a n y  o th e r p a y o rs o r in su re rs, a n d  th e ir r e sp e c tive  a g e n ts o r co n tra cto rs, a s m a y  b e  </div>
<div id="t55_1" class="text" style="word-spacing: 1px; font-size: 7px;">n e c e ssa ry  to  d e te rm in e  th e se  o r o th e r  b e n e fits p a y a b le  fo r a n y  se r vic e s p ro vid e d  to  m e  b y  SEQ  MC C U, n o w , in  th e  p a st, o r in  th e  fu tu re . </div>
<div id="t56_1" class="text" style="word-spacing: 3px; font-size: 7px;">N e w  York  N o-Fa ult M otor Ve hic le  Ins ura n c e  La w  As s ig nm e nt of Ins ura nc e  Be ne fits  </div>
<div id="t57_1" class="text" style="word-spacing: 1px; font-size: 7px;">In  c o n sid e ra tio n  fo r se r vic e s re n d e re d  o r to  b e  r e n d e r e d  to  th e  a b o ve  n a m e d  p a tie n t, I h e re b y  a u th o rize  p a y m e n t d ire c tly  to  th e  a b o ve  n a m e d  h o sp ita l, p h y sic ia n  o r o th e r p ro vid e r  </div>
<div id="t58_1" class="text" style="word-spacing: 1px; font-size: 7px;">o r h e a lth  ca re  se r vic e s o f a n y  a n d  a ll first p a rty  n o -fa u lt au to m o b ile  in su ra n c e  b e n e fits to  w h ic h  I m a y  o th e rw is e  b e  e n title d  fo r se rvic e s re n d e re d  b y  th e  p ro vid e r, b u t n o t to  e xc e e d  </div>
<div id="t59_1" class="text" style="word-spacing: 1px; font-size: 7px;">th e  p ro vid e r’s c h a rg e s fo r su c h  se rvic e s. </div>
<div id="t60_1" class="text" style="word-spacing: 1px; font-size: 7px;">In  th e  e ve n t th e  p ro vid e r’s c h a rg e s a re  o u tsta n d in g  a n d  I fa il to  file  a n  a p p lic a tio n  fo r b e n e fits u n d e r th e  Ne w  Yo r k  Sta te  No -Fa u lt In su ra n ce  </div>
<div id="t61_1" class="text" style="word-spacing: 1px; font-size: 7px;">La w , I h e re b y  a u th o rize  th e  p r o vid e r to  file  su c h  c la im  o n  m y  b e h a lf so  th a t th e  p r o vid e r m a y  re a lize  p a y m e n t fo r c h a r g e s. </div>
<div id="t62_1" class="text" style="word-spacing: 1px; font-size: 7px;">I un d e rsta n d  th a t, if th e  p ro vid e r d o e s n o t re c e ive  </div>
<div id="t63_1" class="text" style="word-spacing: 1px; font-size: 7px;">p a y m e n t fro m  th e  in su r e r, I a m  p e rso n a lly  re sp o n sib le  fo r th e  p a y m e n t o f th e  p r o vid e r’s c h a r g e s.</div>
<div id="t64_1" class="text" style="word-spacing: 2px; font-size: 9px;">If the  p atie nt sig ns with an “X” or othe r m ark, a witne ss should  sig n b e low </div>
<div id="t65_1" class="text" style="word-spacing: 16px; font-size: 10px;">X _____________________________________  ______________    X ____________________________________ </div>
<div id="t66_1" class="text" style="font-size: 10px;">______________</div>
<div id="t67_1" class="text" style="word-spacing: 3px; font-size: 10px;">Pa tie nt Sig na ture  or Ma rk </div>
<div id="t68_1" class="text" style="word-spacing: 0px; font-size: 10px;">Date  </div>
<div id="t69_1" class="text" style="word-spacing: 3px; font-size: 10px;">W itne ss Sig na ture  </div>
<div id="t70_1" class="text" style="word-spacing: 0px; font-size: 10px;">Da te  </div>
<div id="t71_1" class="text" style="font-size: 10px;">A.</div>
<div id="t72_1" class="text" style="word-spacing: 1px; font-size: 10px;">Am bulanc e  Cre w  M e m be r State m e nt (</div>
<div id="t73_1" class="text">m us t</div>
<div id="t74_1" class="text">be  c om ple te d by  c re w  m e m be r at tim e  of trans port)</div>
<div id="t75_1" class="text" style="word-spacing: 3px; font-size: 10px;">My sig nature  b e low ind icate s that, at the  time  of se rvice , the  patie nt name d  ab ove  was p hysically or me ntally incap ab le  of sig ning , and  that </div>
<div id="t76_1" class="text" style="word-spacing: 3px; font-size: 10px;">none  of the  authorize d  re p re se ntative s liste d  in Se ction II of this form we re  availab le  or willing  to sig n on the  patie nt’s b e half. </div>
<div id="t77_1" class="text" style="word-spacing: 4px; font-size: 10px;">M y signature  is </div>
<div id="t78_1" class="text" style="word-spacing: 3px; font-size: 10px;">not an acce ptance  of financial re sponsibility for the  se rvice s re nde re d.</div>
<div id="t79_1" class="text" style="word-spacing: 3px; font-size: 10px;">On the  line  b e low, e xp lain the  circumstance s that make  it impractical for the  p atie nt to sig n: </div>
<div id="t80_1" class="text" style="word-spacing: 0px; font-size: 10px;">______________________________________________________________________________________________________________________ </div>
<div id="t81_1" class="text" style="word-spacing: 7px; font-size: 10px;">Name  and  Location of Re ce iving  Facility: _______________________________________________________________________________________ </div>
<div id="t82_1" class="text" style="word-spacing: 4px; font-size: 10px;">Time  at Re ce iving  Facility: ____________________________ </div>
<div id="t83_1" class="text" style="word-spacing: 0px; font-size: 10px;">X ___________________________________________    _______________ </div>
<div id="t84_1" class="text" style="word-spacing: 0px; font-size: 10px;">_____________________________________________________________ </div>
<div id="t85_1" class="text" style="word-spacing: 3px; font-size: 10px;">Sig nature  of Cre wme mb e r </div>
<div id="t86_1" class="text" style="word-spacing: 0px; font-size: 10px;">Date  </div>
<div id="t87_1" class="text" style="word-spacing: 3px; font-size: 10px;">Printe d  Name  and  Title  of Cre wme mb e r</div>
<div id="t88_1" class="text">B.</div>
<div id="t89_1" class="text" style="word-spacing: 3px; font-size: 10px;">Re c e iving  Fac ility  Re pre s e ntative  Sig nature  </div>
<div id="t90_1" class="text" style="word-spacing: 3px; font-size: 10px;">The  patie nt name d  on this form was re ce ive d  b y this facility at the  d ate  and  time  ind icate d  ab ove . </div>
<div id="t91_1" class="text" style="word-spacing: 4px; font-size: 10px;">M y signature  is not an acce ptance  of </div>
<div id="t92_1" class="text" style="word-spacing: 2px; font-size: 10px;">financial re sponsibility for the  se rvice s re nde re d to this patie nt.</div>
<div id="t93_1" class="text" style="word-spacing: 0px; font-size: 10px;">___________________________________________ </div>
<div id="t94_1" class="text" style="word-spacing: 0px; font-size: 10px;">_________________    _____________________________________________________________ </div>
<div id="t95_1" class="text" style="word-spacing: 3px; font-size: 10px;">Sig nature  of Re ce iving  Facility Re p re se ntative  </div>
<div id="t96_1" class="text" style="word-spacing: 0px; font-size: 10px;">Date  </div>
<div id="t97_1" class="text" style="word-spacing: 2px; font-size: 10px;">Printe d  Name  and  Title  of Re ce iving  Facility Re p re se ntative</div>
<div id="t98_1" class="text" style="word-spacing: 9px; font-size: 14px;">SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE </div>
<div id="t99_1" class="text" style="word-spacing: 8px; font-size: 10px;">Complete this section </div>
<div id="t100_1" class="text" style="font-size: 11px;">only</div>
<div id="t101_1" class="text" style="word-spacing: 5px; font-size: 10px;">if the patient is physically or mentally incapable of signing. </div>
<div id="t102_1" class="text" style="word-spacing: 3px; font-size: 7px;">SEC TIO N  I - P ATIEN T SIG N ATURE</div>
<div id="t103_1" class="text" style="word-spacing: 1px; font-size: 7px;">Th e  p a tie n t m u st sig n  h e re  u n le ss th e  p a tie n t is p h y sic a lly  o r m e n ta lly  in c a p a b le  o f sig n in g . NO TE: if th e  p a tie n t is a  m in o r, th e  p a r e n t o r le g a l g u a rd ia n  sh o u ld  sig n  in  </div>
<div id="t104_1" class="text" style="word-spacing: 1px; font-size: 7px;">th is se c tio n .</div>
<div id="t105_1" class="text" style="word-spacing: 7px; font-size: 14px;">SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES</div>
<div id="t106_1" class="text" style="word-spacing: 8px; font-size: 10px;">Complete this section </div>
<div id="t107_1" class="text" style="font-size: 11px;">only</div>
<div id="t108_1" class="text" style="word-spacing: 5px; font-size: 10px;">if: (1) the patient was physically or mentally incapable of signing, </div>
<div id="t109_1" class="text" style="font-size: 11px;">and</div>
<div id="t110_1" class="text" style="word-spacing: 4px; font-size: 10px;">(2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service. </div>

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